Chronic obstructive pulmonary disease mobile care: A participant-focussed and human rights-based evaluation

Abstract

To reduce healthcare costs associated with chronic obstructive pulmonary disease (COPD) and vacate hospital beds without compromising patient satisfaction with healthcare, alternatives for hospital treatment have been developed; however, few studies have qualitatively investigated patients’ experiences of these alternatives. This study aimed, first, to explore patients’ experiences of Sweden’s first COPD mobile care programme through semi-structured interviews with twelve patients, and, second, to evaluate if a human rights-based analysis could provide additional information. Data were, first, analysed using latent content analysis, resulting in three themes: security (effective follow-up, positive encounters), availability (convenience), and suggestions for improvement (increased amount of personnel, longer enrolment period, continued follow-up upon discharge from the programme). Security and availability contributed to high acceptability of and satisfaction with the programme; COPD mobile care can, thus, constitute an acceptable alternative to inpatient care for COPD patients. Findings were then further analysed using the AAAQ framework (availability, accessibility, acceptability, and quality) to determine how the COPD mobile care programme corresponds to the Right to health. This human rights-based analysis enabled the uncovering of certain groups being excluded from the programme, thereby generating valuable information for improving the programme by ensuring equal access and care for all COPD patients.

Keywords

COPD early supported discharge hospital at home qualitative research human rights-based analysis right to health

Introduction

Chronic obstructive pulmonary disease (COPD), a leading cause of mortality and morbidity worldwide and currently ranked as the fourth major cause of death globally,^1,2 is a chronic disease that causes limitations in the lung airflow and is characterised by breathlessness, excessive sputum production, and chronic cough.³ In Sweden, the number of cases is estimated to be over 500,000 but undiagnosed cases are prevalent; the slow progressive nature of COPD contributes to patient and healthcare delays in the detection of the disease.⁴

Exacerbations are common events during the course of COPD and defined as ‘an acute event characterised by a worsening of the patient’s respiratory symptoms that is beyond normal day-to-day variations and leads to a change in medication’.⁵ Acute exacerbation is one of the major causes of hospitalisation for COPD patients and contributes to high healthcare costs.⁶ Furthermore, acute exacerbations that result in frequent hospitalisations have also been shown to reduce survival⁷ and impair quality of life for COPD patients.⁸

To reduce healthcare costs and vacate hospital beds without compromising patient satisfaction with healthcare, alternatives for hospital treatment have been developed. Two such common alternatives are early supported discharge (ESD) and hospital at home (HaH) schemes. The focus of these schemes is to identify COPD hospital patients with acute exacerbations who could be discharged earlier by providing increased support in their homes consisting of arranged nursing visits in patients’ homes during a limited period of time. ESD and HaH schemes have been carried out and studied in randomised controlled trials,^9–11 non-randomised trials,^12,13 retrospective analyses,¹⁴ and in literature reviews¹⁵ worldwide. Studies have shown that ESD and HaH schemes are a safe alternative to inpatient care for selected COPD patients with acute exacerbations^9,11,15 and that these schemes can reduce the length of hospital stay,^9,13,15 reduce readmission rates,^10,14 and contribute to cost savings in healthcare^10,11,13 Furthermore, there is evidence that ESD and HaH schemes are a preferable treatment option compared with hospitalisation among patients and families; several studies report greater patient satisfaction with these schemes than with hospitalisation.^10,11,16

Previous qualitative studies on ESD and HaH schemes have found that patients in a home care programme appreciated the individually adapted information and experienced safety and a positive impact on COPD self-management strategies¹⁷ but also that these schemes are not beneficial to all patients.¹⁸ The authors noted that patients experienced that they were not being actively involved in the ESD process and that there were organisational problems in the procedure of ESD that might have contributed to the patients’ lack of beneficial experiences of the programme. Qualitative studies on patients’ experiences of ESD and HaH schemes are, however, few and there is still a need for the evaluation of the different schemes. Thus, this study aimed to, first, qualitatively investigate patients’ experiences of the first ever COPD mobile care programme in Sweden, operated by Angered Hospital.

Furthermore, Angered Hospital applies a human rights-based approach which entails assessing how offered health services fulfil requirements with respect to the AAAQ framework: availability, accessibility, acceptability, and quality of health services.¹⁹ Therefore, the second aim of this study was to evaluate if a human rights-based analysis could provide additional information to the patients’ experiences of the COPD mobile care programme.

Methods

The COPD mobile care programme

The COPD mobile care programme at Angered Hospital is an alternative to inpatient care but not equivalent to home care service or rehabilitation. The focus is to follow up patients in their homes after hospital admission. Angered Hospital has the capacity to care for a limited number of patients depending on number of nurses; at the time of this study, the mobile care team consisted of two full-time specialised respiratory nurses. As of March 2013, 79 patients had been enrolled in the programme since its commencement in 2010.

Patients are recruited among those admitted for a mild exacerbation to the medical and pulmonary wards at Sahlgrenska University Hospital in Gothenburg. Existing guidelines only recommend mobile COPD care for certain patients due to patient safety from a medical perspective.¹⁵ This precludes the admission of patients with severe exacerbations, which limits the number of potential patients to recruit. Recruitment is done according to a screening sheet evaluating the ability of the patient to participate in the programme, taking into account factors such as severity of the illness and exacerbation, comorbidity (those with acute severe dyspnoea, metabolic, or cardiovascular conditions are excluded), living conditions, and ability to communicate in case of an acute worsening of the patient’s condition. Patients approved to participate are transferred to policlinic care at home, carried out by the COPD mobile care team.

A team nurse visits the patient before hospital discharge, followed by home visits every second day during which the patient’s clinical and medical status, inhalation technique and respiratory technique are evaluated. The patient’s health, information on COPD, and self-management of COPD are also discussed. If needed, nurses can also facilitate contact with dieticians, physiotherapists, or occupational therapists. Every visit lasts approximately 1 h. Days between visits patients are assessed by phone calls. The recommended length of stay in the programme is 14 d, during which patients are allowed additional visits if needed. Patients experiencing a worsening in symptoms are readmitted to the hospital. Patients are allowed to participate in the programme more than once, but participation on regular basis is not recommended.

Participants

The study was conducted between March and April 2013. Because some COPD patients suffer from reduced capacity to absorb oxygen, which could contribute to impaired memory function,²⁰ we decided to only include patients enrolled in the programme from 1 January 2012 to 31 March 2013 in order to minimise recall problems among participants. Thirty-eight patients had been enrolled in the programme during this period. Eight were deceased by the time of the study, seven were excluded due to impaired health situations, and one was excluded due to insufficient contact with the COPD mobile care team. The remaining 22 patients were invited to participate in the study. We first sent patients an information letter outlining the study and thereafter phoned them within 2 or 3 days. Ten patients declined to participate; the remaining 12 agreed and were interviewed. Characteristics of participants are presented in Table 1. The declining patients mainly differed in that the majority were women, lived alone, were in a progressed stage of their illness (GOLD stage IV), and had two or more coexisting diseases.

Table 1.

Sample characteristics (n = 12).

Characteristic		n
Sex	Male	5
Sex	Female	7
Age	60–69 years	4
	70–79 years	5
	80–89 years	2
	90+ years	1
Living situation	Lives alone	6
Living situation	Cohabits	6
Country of birth	Sweden	11
Country of birth	Other European country	1
Comorbid conditions^a	0	4
	1	2
	2	2
	3+	4
GOLD stage^b	I	0
	II	0
	III	2
	IV	10
Body mass index (kg/m²)	<22	4
	22–30	6
	>30	2
Number of times participated in the COPD mobile care program	1	4
	2	7
	3	1
Length of participation, first time (mean days and interval)	17 (8–34)	12
Length of participation, second time (mean days and interval)	17 (7–28)	8

Co-existing diseases, e.g., cardiovascular diseases, osteoporosis, and depression.

GOLD, the Global Initiative for Chronic Obstructive Lung Disease.

Data collection

A qualitative inductive approach was adopted to gain a deeper knowledge and understanding of patients’ experiences of the COPD mobile care programme derived from data without limitations imposed by structured methodologies or a priori theories.²¹ Data were obtained through semi-structured, audio-taped interviews based on Kvale’s principles.²² All participants were provided with a participant information sheet about their right to withdraw from participation, confidentiality, and advantages and disadvantages of participation, and asked to sign a consent form before the interviews. The study was scrutinised by Angered Hospital management for ethical consideration and approval was obtained, as per instructions by the Regional Ethical Review Board and in accordance with Swedish laws on research ethics.

The interview guide consisted of open-ended questions about patients’ experiences of the COPD mobile care programme, for example ‘How did you experience the COPD mobile care programme?’ and ‘How has participation in the programme affected your health situation?’ All questions in the guide were covered during interviews but if other relevant topics were raised by participants then these were followed up and explored too. All interviews were conducted in Swedish, located in the patients’ homes and lasted between 20 and 50 min. Patients’ ill-health accounted for the shorter interviews; 10 patients had severe symptoms such as breathlessness and cough which made them too tired and exhausted for longer conversations. Three spouses were present during the interviews and provided supplementary information to varying extent depending on the patient’s health status and communication ability.

Data analysis

We analysed data, first, using qualitative latent content analysis.²³ Upon transcription of interviews, the analysis followed all steps defined by Graneheim and Lundman: reading through the material to obtain an overall impression, identifying units of meaning about patients’ experiences of the COPD mobile care programme and coding of these, condensing and summarising the content of each of the coded groups, integrating the insight from the condensed units into categories, and finally describing the latent content of the text expressed in themes.²³ The second author conducted the interviews, the transcription, and main data analysis; the analysis was then validated by all co-authors. In addition, two external colleagues independently validated the analysis by studying a random sample of one-fourth of the transcripts. They were instructed to highlight words and phrases that they believed answered the question ‘How have patients experienced the COPD mobile care programme?’ This process resulted in confirmation of some themes, while others were adjusted. Finally, extracts were translated into English by the research team.

The content analysis results were then further analysed using the AAAQ framework to assess compliance with the human right of everyone to the enjoyment of the highest attainable standard of physical and mental health (henceforth ‘the Right to health’).²⁴ AAAQ is considered ‘an important analytical framework to state and non-state actors alike in assessing what adequate compliance with this right requires practically’.²⁵ This second analysis entailed assessing the content analysis results from a AAAQ perspective:¹⁹ Are functioning healthcare facilities available in sufficient quantity? Are healthcare facilities and information accessible to all without discrimination, including being physically accessible and economically affordable? Are healthcare facilities acceptable from perspectives such as medical ethics, culture, gender, and age? Are healthcare facilities scientifically and medically appropriate and of good quality?

Results

Content analysis

The content analysis resulted in three themes: security, availability, and suggestions for improvement.

Security: Participants’ overall impression of the COPD mobile care programme was that of security. Different aspects of security were described but were mainly related to two categories: effective follow-up and positive encounters. Participants emphasised the effective follow-up as very important for their feelings of security in the programme. Daily examinations of clinical parameters, information about the disease, and disease management advice from the visiting nurse contributed to their feeling secure. Several participants also reported that the information and management strategies had increased their level of knowledge of the disease, which contributed to an even greater feeling of security which in turn affected their health in a positive way as their self-management capacity was enhanced and they felt empowered.

‘The health changed because much of my anxiety disappeared. Since I got a sense of security and I don’t get so nervous, the breathing improves’. (Participant 12)

Some, however, mentioned that the information and the self-management strategies were sometimes overwhelming due to their often poor health condition. Some described how their commitment to the breathing exercises varied from day to day depending on their health status. Excessive tiredness and high time-consumption were reported as the two main reasons for not engaging in the breathing exercises; although one participant reported disregarding the breathing exercises when feeling better. Many stated having acquired new knowledge about the disease from the programme. Others mentioned that they had already received information from other care programmes, and the information from this one only confirmed what they already knew. Some also said there was nothing new to learn that could help them overcome an incurable disease. One reported that the only thing that was new was the increased feeling of security.

Several participants stated that they were initially sceptical about the programme due to being unaware of what it entailed. Lacking information about the programme at the time of discharge from hospital and feelings of too much occurring in connection with the discharge process were mentioned as reasons for scepticism. They agreed, however, to participate in the programme and noted that they were very satisfied once they had received the right information and knew what to anticipate. Some also mentioned that they felt privileged having received the service.

‘The doctor asked me if I wanted to have it and I didn’t know what it was but I said yes immediately. Yes I did, because I thought that then someone will come home to me and then I will feel safe’. (P8)

Communication was also highlighted as an important part of the effective follow-up, which contributed to feelings of security. Regular home visits and telephone consultation with nurses were highly valued. Participants emphasised that just knowing that someone would visit them after discharge from hospital made them feel secure. Furthermore, several described how beneficial and comforting it was to have time for asking questions and talking with the nurse during visits.

‘They kept in touch all the time. When they weren’t here, they called me very often to ask me how I felt and I appreciated it very much’. (P11)

Another aspect of security raised was the positive encounters with the nurses. All participants described how well they had been taken care of by the nurses. They remarked that the nurses showed an interest in how they felt and took time to listen to their worries and problems. Several mentioned that they felt they were taken seriously and shown respect, in contrast to nurses in primary care. One participant reported stigmatising experiences at the primary care centre because of the nurses’ disrespectful attitudes towards former smokers with COPD. All participants described the COPD mobile care nurses as caring, engaged, and very pleasant persons whom they considered trustful and to be a close friend.

‘It was just like I had known her forever. No it was nothing, it was just like I had known them forever. So, it’s different people you can talk to, some you can’t talk to at all. So no, it was great, it was no problem’. (P8)

Reliance on nurses’ competence also emerged as an important part of positive encounters, which contributed to feelings of security. How nurses explained things, gave concrete advice, and communicated clinical results increased participants’ trust and confidence in nurses’ competence. Nurses were described as very knowledgeable and accurate in their work, which made participants feel that they were in safe hands.

‘They are competent because they know what they are doing, regarding the COPD. I know a little fraction but they know everything’. (P6)

In conclusion, participants’ feelings of security were mainly related to effective follow-up and positive encounters, namely daily examinations of clinical parameters, information and disease management advice, continuous communication, and nurses’ engagement and competence.

Availability: Different aspects of availability were highlighted as important. Several participants mentioned that enrolment in the programme allowed them to evade readmission or transport to hospital, resulting in this type of care being considered more convenient in comparison to traditional hospital care.

‘It was great because you know when you get ill you didn’t have to go to the hospital every time because they did much of the hospital’s [work] otherwise I would have had to go in’. (P12)

The provision of medical resources to patients’ homes, rather than having to visit the hospital to obtain items, was also highly valued by some, as well as their partners. The care received through the COPD mobile care programme, thus, positively impacted patients as well as their family. The availability was also described in terms of the nurses being approachable. Several participants reported having no difficulty getting in touch with the nurses if needed. One person described how convenient and easy it was to know where to call when feeling poor or when new questions arose compared to when not participating in the programme.

‘If I had questions to the doctor, I could call them [the COPD mobile care nurses] and ask them to contact the doctor’. (P5)

In sum, availability was mainly related to feelings of convenience in the programme. To evade readmission or transport to hospital and to know where to turn to in times of illness was highly appreciated and contributed to their feelings of convenience.

Suggestions for improvement: All participants found the COPD mobile care programme very satisfying. Nevertheless, some stated that certain aspects of the programme could be improved. The most common suggestion that emerged was the need for expansion, mainly in relation to the high prevalence of COPD patients in the area which limited the opportunity for all patients to participate in the programme. Many found this unfair and one participant suggested a redistribution of financial resources in the healthcare sector in order to prioritise the COPD mobile care programme.

Another aspect of expansion expressed was the limited amount of personnel in the programme. Some mentioned that only two nurses could impossibly be able to care for all COPD patients who wanted to participate in the programme. Some also suggested that the amount of personnel should be adapted to the amount of patients in the programme.

‘They should have had more personnel in the beginning because when she came she had not much to do but in the end they had received so many patients so they had a shitload to do’. (P12)

Several also described the length of the enrolment period as an aspect in need of improvement. While a majority of participants were satisfied with the recommended length of stay, some wished for a longer stay or more frequent contact with nurses while in the programme. Some also wanted to be followed up at Angered Hospital or via telephone upon discharge from the programme.

‘Perhaps they should continue to keep in touch. They don’t need to come here but perhaps they could call me every fortnight and after that every third week and then once a month’. (P1)

In sum, participants emphasised expansion, increased amount of personnel, longer enrolment period, and continued follow-up upon discharge as suggestions for improvement.

AAAQ analysis

An application of the AAAQ framework onto the content analysis results suggests that the COPD mobile care programme corresponds well to the Right to health. First, the service contributes towards ensuring the availability of healthcare services for COPD patients. With the expected increase in COPD prevalence,^1,5 it is likely that the demand for COPD healthcare will increase in the years to come. Paradoxically, the capacity to care for patients in hospital has decreased as a result of reduced numbers of hospital beds,²⁶ which implies an increased demand for alternatives to inpatient care in order to maintain high-quality care for patients suffering from diseases such as COPD. Mobile care, such as offered by Angered Hospital, may be one way of meeting such demands. Furthermore, participants were generally very satisfied with the programme and, thus, presumably perceived the care to be acceptable and of good quality.

The AAAQ analysis, however, highlighted that current programme logistics may compromise aspects of accessibility due to an inclusion criterion excluding individuals with insufficient Swedish language skills, that is, particularly vulnerable individuals. Although in practice the COPD mobile care team only operates during daytime because Angered Hospital is a daytime only hospital, the hospital, nonetheless, carries responsibility for patients at all times. Patients with communication barriers are, thus, not included due to the imminence of an acute worsening of patients’ condition during call time and the risks inherent therein if patients are unable to communicate their needs to the mobile care team. Because of limited healthcare resources for COPD patients, there is thus a risk that patients with insufficient language skills do not receive the care they need on equal terms as patients with sufficient language skills.

Discussion

This was the first study investigating patients’ experiences of a COPD mobile care programme in Sweden. The key finding was participants’ experiences of security in the programme, which mainly entailed their positive experiences of the effective follow-up and positive encounters with the COPD mobile care nurses. We found that daily examinations of clinical parameters, information and disease management advice, continuous communication, and nurses’ engagement and competence contributed to feelings of security. Moreover, the experiences of feeling secure increased when patients felt more knowledgeable about managing the disease. Another important finding in our study was the general experience of the COPD mobile care programme as available and convenient. To evade readmission or transport to hospital while in the programme and to know whereto turn in times of illness was highly appreciated and contributed to feelings of convenience. Participants were overall very satisfied with the programme but expressed certain suggestions for improvement such as expansion, increased amount of personnel, longer enrolment period, and continued follow-up upon discharge from the programme.

Our study corroborates findings from previous studies on ESD and HaH schemes conducted in other countries. For example, we found that knowing that someone would visit them after discharge from hospital lead to patients’ feeling secure, which supports results from a previous study.¹⁷ This, however, seems to contrast the results from another study that found that not all patients perceived the nurse visits helpful, mainly due to patients’ lack of involvement and negotiation in the ESD process.¹⁸ Our results also indicate that availability and convenience of services increased feelings of security. Furthermore, similar to Wang et al.,¹⁷ we found that feelings of security were of crucial importance to acceptance and satisfaction with the programme, and in a mixed-method study, patient satisfaction with the HaH scheme was particularly associated with its accessibility and ease of use¹⁶ Altogether these findings suggest that availability, convenience, and security are related to patient satisfaction.

In contrast to the supported findings of patient satisfaction with ESD and HaH schemes, Clarke et al.¹⁸ suggested that patients’ dissatisfaction with care might be explained by the characteristics of local populations, where patients from socioeconomically disadvantaged areas tend to give lower ratings of care. Our study, however, did not reflect this assertion despite Angered Hospital being located in a generally socioeconomically disadvantaged area.

Studies on ESD and HaH schemes have mostly focussed on the quantitative effects of these schemes such as reduced readmission, length of hospital stay, and cost-effectiveness rather than an evaluation of patients’ experiences of ESD and HaH schemes. Our study uniquely highlights, from patients’ own perspectives, aspects of COPD mobile care that can be improved. To our knowledge, previous studies have not explicitly addressed patients’ suggestions for improvement of ESD or HaH schemes. Continuous evaluation of ESD schemes is of great importance in order to improve and develop such schemes within different contexts – not least due to the likely increase in demand for COPD healthcare in the years to come, which, together with reduced numbers of hospital beds,²⁶ necessitates alternatives to inpatient care. A national expansion of COPD mobile care may be one alternative for meeting the demands. An expansion of the COPD mobile care in line with participants’ suggestion – to offer COPD mobile care to all patients – may, however, not be appropriate. Given participants’ positive experiences of the programme at Angered Hospital – such as their sense of security – their desire for all participants to have the same positive experiences is understandable. As mentioned, however, from a medical perspective, COPD mobile care in its current form is not suitable for all COPD patients due to existing patient safety guidelines.¹⁵

Another accessibility-related challenge for the present COPD mobile care arises from the fact that although Angered Hospital operates the COPD mobile care programme, the supply of patients is governed by two administrations: Angered Hospital and Sahlgrenska University Hospital. The collaboration entails logistical challenges in ensuring that all potential patients are identified and referred to the programme.

A third factor limiting accessibility is that patients with insufficient Swedish communication skills are excluded to participate in the programme.

The issue of limited accessibility is not consistent with the Right to health if effected by factors other than patient safety from a medical perspective. Therefore, it is crucial to identify solutions for meeting the potential increase in COPD healthcare demands and ensuring that all individuals receive essential care in order to realise the Right to health as a human right – an imperative obligation for health services management. Owing to states’ endorsing of human rights conventions, such as those declaring the Right to health,²⁴ health services are obliged to fulfil this human right. This requires health services managements to identify and address potential shortcomings with respect to AAAQ. For the present programme, perhaps developing a structure involving (telephone) interpreters will allow patients with insufficient language skills to benefit from COPD mobile care in a medically safe manner.

Seemingly, an application of the AAAQ framework to evaluations of healthcare services can generate valuable, otherwise potentially obscured, knowledge and information for the management of such services by determining whether a programme, intervention, or service complies with guidelines regarding the Right to health. The findings from this study show that Sweden’s first COPD mobile care programme corresponds well to the Right to health while certain aspects are in need of improvement. Figure 1 illustrates the implications of our findings for healthcare managers.

Figure 1.

A participant-focussed and human rights-based evaluation of COPD mobile care.

Notwithstanding the importance of our findings, our study has limitations to consider. First, there is the issue of potential selection bias. Patients’ health situation at the time may have influenced their willingness to participate in the study, especially because many patients had reached a severe stage in their illness which decreased their possibility to partake in the study. Those with severe symptoms who participated were possibly too tired to give comprehensive accounts of their experiences of the programme; however, all participants answered all interview questions and in the case of less comprehensive answers, follow-up questions were asked after considering patients’ health status. Another aspect may be that patients more positive towards the programme were more likely to participate. It is important to keep in mind that eight out of 12 patients had been enrolled in the programme previously, which may have contributed to their positive experiences of the programme and so on their willingness to participate.

Second, it is possible that involvement of spouses in three interviews may have affected participants’ answers, perhaps by influencing them to respond in a particular way or recalling a particular memory. Nevertheless, we believe that the spouses’ supportive role and attendance provided valuable supplementary information when patients struggled with breathlessness or memory problems during the interviews.

Finally, although participants consisted of a relatively small group of patients, we obtained diversity in our sample regarding age, gender, living situation, and comorbid situation (Table 1). Unfortunately, we did not manage to reach diversity in our sample regarding country of birth as a result of the low participation rate among foreign-born patients in the programme. This is surprising considering the high proportion of foreign-born patients who live in the catchment area of Angered Hospital. Arguably, foreign-born patients’ inability to communicate in case of an acute worsening of their condition limits the possibility for them to participate in the programme, as discussed previously. We, nonetheless, believe that the sample diversity together with participants’ range of experiences of the programme offer a useful introduction into understanding the experience of COPD mobile care.

The use of external coders further endorsed our analysis. Although the external coders only identified roughly 60% of the codes identified by the research team, the discrepancy can be explained by the fact that the research team was more knowledgeable on the topic and more familiar with the material and consequently identified more codes. More importantly, the few codes that the external coders identified but not the research team, and their relevance to the research objective, were discussed and this validation process resulted in a confirmation of some themes and modification of others.

Conclusion

In the years to come, the prevalence of COPD is expected to increase, which is likely to implicate an increased demand for healthcare. ESD and HaH schemes have been successful in decreasing hospital readmission, length of hospital stay, and healthcare costs for COPD patients with acute exacerbations. We conclude that COPD mobile care can constitute a secure, available, and acceptable alternative to inpatient care for COPD patients. An application of the AAAQ framework further generates valuable information for improving such care by ensuring equal access and equal care for all COPD patients in accordance with the Right to health as a human right.

Footnotes

Acknowledgements

The authors gratefully acknowledge the valuable assistance of COPD nurse Lotta Sjöstrand for her enthusiastic cooperation and contribution of information throughout the study, and the participants for enabling this study to be carried out.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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